Heart, Lung and Circulation最新文献

Background: Unplanned readmissions in patients with acute heart failure generate a substantial burden on healthcare systems and are associated with significant morbidity and mortality. Heart failure admissions are projected to increase over time with the ageing population. Understanding the factors contributing to readmissions after an index admission for heart failure is important, in order to develop strategies to address this phenomenon.

Aim: To understand the patient and organisational factors that contribute to readmissions in patients who are admitted with acute heart failure.

Method: Qualitative content analysis was performed on clinical notes from electronic medical records of all patients readmitted within 30 days after admission with acute heart failure at a single tertiary referral centre, between June 2022 and January 2023. Text related to patient and system-related factors contributing to readmissions were coded and organised into categories and sub-categories. The frequency of codes per patient was generated as a surrogate marker of the relative importance of codes within the dataset.

Results: Overall, 64 patients were readmitted within the study timeframe. Three main categories emerged from the analysis, including patient-related medical factors contributing to readmission, patient-related psychosocial factors, and system-related factors. Patient-related medical factors were the most dominant category, with sub-categories of "non-heart failure causes of readmission", "frailty or functional decline", or "severe underlying cardiac pathology" occurring most frequently within the cohort (60.9%, 48.4%, 42.2%, respectively).

Conclusions: This study explores the patient-related medical, psychosocial, and system-related factors as significant contributors to readmissions in acute heart failure patients. It underscores the need for comprehensive and multi-faceted interventions to improve patient outcomes in this population and reduce healthcare burdens.

Aim: Cox-maze IV is the most effective surgical procedure for atrial fibrillation (AF) treatment to date; however, few studies have compared the outcomes of the different energy sources applied to achieve transmurality. This study aimed to analyse the impact of the different energy sources on Cox-maze IV results in terms of sinus rhythm restoration.

Method: A systematic review and meta-analysis was conducted by including studies reporting rhythm outcomes on biatrial Cox-maze AF ablation with bipolar radio-frequency (BRF), cryoenergy (Cryo), or both (BRF+Cryo). The primary endpoints were the early and late rhythm outcomes of AF ablation using the different energy sources. Late AF recurrences were evaluated through timepoint analysis, and freedom from AF from Kaplan-derived data. Sixty articles including 8,293 patients were selected (3,364 patients Cryo, 1,937 BRF, and 2,992 BRF+Cryo).

Results: At 6 months, AF incidence was significantly lower in the Cryo group at 6.73%; it was 25.52% in the BRF and 16.79% in the BRF+Cryo groups (p=0.0112). At the 4-year timepoint, AF incidence was lower in the Cryo group compared with the BRF and BRF+Cryo: 6.14% vs 51.59% vs 16.09%, respectively (p=0.0392). Freedom from AF was 76.7%±2.2%, 60.9%±2.2%, and 66.3%±1.6% for Cryo, BRF, and BRF+Cryo at 4 years, respectively (p<0.001). At meta-regression, mean left atrial diameter was positively associated with higher AF recurrences (OR 1.04, 95% CI 1.01-1.08; p=0.0159).

Conclusion: When performing this procedure, cryoablation seems to be associated with improved rhythm outcomes when compared with bipolar radiofrequency ablation.

Background & aim: Individuals with congenital heart disease (CHD) have reduced cardiorespiratory fitness which is associated with poor prognosis and quality of life. Evidence shows that exercise is effective in the management of adults with CHD. However, uncertainties remain about the safety and efficacy of high-intensity interval training (HIIT) in these patients. We performed a systematic review to assess the effects of HIIT on aerobic capacity and quality of life in adults with CHD.

Methods: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Collaboration Handbook.

Results: As only three studies fitting the inclusion criteria could be included, with a total of 87 adults with CHD, we identified a major need for more studies assessing the effect of HIIT. Although HIIT appeared to improve peak oxygen uptake, other measures were inconclusive due to limited studies.

Conclusion: Available evidence to date suggests that HIIT improves aerobic capacity in adults with CHD with no serious adverse events. However, these data are too limited and are to be viewed with caution, identifying an important need for future studies to determine the direct impact of HIIT and to compare HIIT with other exercise intensity modalities.

Aim: Physician visual assessment (PVA) in invasive coronary angiography (ICA) is clinically used to determine stenosis severity and guide coronary intervention. However, PVA provides limited information regarding the haemodynamic significance of stenosis. This prospective study aimed to develop a model combining visual diameter stenosis (DS_PVA) and quantitative coronary angiography (QCA)-derived parameters to diagnose ischaemic lesions using invasive fractional flow reserve (FFR) with pharmacologically induced maximal hyperaemia as the gold standard.

Methods: A total of 103 patients (148 lesions) who underwent ICA and FFR measurement were included in the study. Quantitative coronary angiography was used to evaluate various parameters, including anatomical parameters such as lesion length (LL), minimal lumen diameter (MLD), and minimal lumen area, along with haemodynamic parameters like LL/MLD⁴ and stenotic flow reserve (SFR). Plaque area, a characteristic parameter of plaque, was also assessed. Lesion-specific ischaemia was defined as invasive FFR ≤0.8.

Results: The LL/MLD⁴ (r= -0.66, p<0.001) and SFR (r=0.66, p<0.001) exhibited inverse and positive correlations, respectively, with invasive FFR. In the multivariable logistic regression analysis, LL/MLD⁴ (≥10.6 mm^-3 vs <10.6 mm^-3; Odds ratio [OR] 10.59, 95% confidence interval [CI] 3.94-28.50; p<0.001) and SFR (≤2.85 vs >2.85; OR 4.38, 95% CI 1.63-11.79; p=0.004) were identified as the optimal dichotomised predictors for discriminating ischaemia. The area under the curve (AUC) was 0.77 using DS_PVA ≥70% as a single predictor. Adding LL/MLD⁴ ≥10.6 mm^-3 and SFR ≤2.85 into the model significantly increased the AUC to 0.87 (p<0.001).

Conclusion: Incorporating QCA-derived haemodynamic parameters provided significant incremental value in the model's discriminatory capability for ischaemic lesions compared with visual diameter assessment alone.

Background: At a global level, regional variation in the management of ST-elevation myocardial infarction (STEMI) is influenced by patient demographics and geography. Rural patients with STEMI are disadvantaged in reaching timely care owing to distance and limited ambulance and healthcare resources. Optimising models of STEMI care is key to overcoming the excess rural vs metropolitan cardiovascular morbidity and mortality. In this descriptive study, we compare patient characteristics and STEMI management in three Local Health Districts (LHDs) across NSW: a rural LHD (Western NSW [WNSWLHD]), a regional LHD (Hunter New England), and a metropolitan site (Sydney LHD).

Method: Data were collected from file audits conducted from 2019 to 2020 in a rural LHD with a single rural 24/7 cardiac catheter laboratory (WNSWLHD), a regional LHD with a part-time rural cardiac catheter laboratory, and a large regional 24/7 cardiac centre (Hunter New England LHD), and a metropolitan site (Sydney LHD), with two 24/7 cardiac centres. Patients with STEMI presenting in the three geographic regions were compared on demographics, differences in presentation, time to reperfusion treatment, time to percutaneous coronary intervention (PCI) centre, distances travelled, proportion of angiograms within 24 hours, and in-hospital mortality.

Results: During 2020, there were 675 recorded STEMI across the three regions. The rural site in WNSWLHD had the highest rate of STEMI per capita, with patients more likely to identify as Indigenous, less likely to call an ambulance, and more likely to present to a non-PCI hospital and to receive thrombolysis. Only 14% of these rural patients received primary PCI (PPCI), with patients presenting a median of 153 km from the PCI centre, vs 69% PPCI in the regional and 89% in metropolitan LHD. Thrombolysis was the main reperfusion treatment in WNSWLHD (76%), and the proportion of patients receiving no treatment was the same in all LHDs at 10%. The percentage of patients receiving angiography within 24 hours in the rural site was 84%. There was no substantial difference in in-hospital mortality among the three LHDs.

Conclusions: We document large differences in the demographic profiles, use of ambulance, and access to PPCI in patients with STEMI across the three NSW centres. Current NSW health and ambulance protocols in a large, sparsely populated rural NSW LHD were able to deliver thrombolysis at the point of contact and facilitate "hot" transfer of patients with STEMI to a PCI centre. Long distances and transfer times mean that PPCI is a limited option in rural NSW, with scope for further improvement in models of care.

Background: Gestational diabetes mellitus (GDM), hypertension during pregnancy (HDP) and/or having small-for-gestational-age (SGA) babies increase cardiovascular disease (CVD) risk. We investigated CVD risk awareness in women with past pregnancy complications and the impact of attending a Women's Heart Clinic (WHC) on this awareness.

Method: Women aged 30-55 years with past GDM, HDP and/or SGA babies were prospectively recruited into a 6-month WHC delivering education and management of CVD risk factors (Melbourne, Australia). A nine-item CVD risk Awareness Survey, consisting of six general/three female-specific questions, was administered at baseline and 6-month follow-up. The primary outcome was a change in overall CVD risk awareness before and after attending a WHC, analysed using a McNemar test. Logistic regression assessed for associations between CVD risk awareness and lifestyle behaviours.

Results: A total of 156 women (mean age 41.0±4.2 years, 3.9±2.9 years postpartum) were recruited with 60.3% past GDM, 23.1% HDP, 13.5% both HDP/GDM and 3.2% SGA babies. The majority were White (68.6%), tertiary-educated (79.5%), and from higher income (84.6%). At baseline, 19.2% (95% confidence interval [CI] 13.0%-25.4%) of women had high overall CVD risk awareness, while 63.5% (95% CI 55.9%-71.0%) had high female-specific CVD risk awareness. At 6-month follow-up, overall CVD risk awareness (19.2%-76.1%, p<0.001) and female-specific CVD risk awareness (63.5%-94.8%; p<0.001) significantly increased. Improvement in CVD risk awareness was not associated with higher physical activity (adjusted odds ratio 0.49; 95% CI 0.04-3.21; p=0.51) or heart-healthy diet (adjusted odds ratio 2.49; 95% CI 0.88-6.93; p=0.08) at 6-month follow-up.

Conclusions: Attendance at a WHC significantly increased women's CVD risk awareness, however, this did not independently associate with lifestyle behaviours.

Background: Lipid-lowering therapy (LLT) is established as a key element in management of patients with coronary artery disease. However, the effect of time of initiation of LLT on outcomes is unclear.

Method: The study compared outcomes of 5,433 patients from Advara HeartCare's Percutaneous Coronary Intervention (PCI) Registry on the basis of timing of LLT initiation classified as pre- or post-PCI admission. The prevalence of acute coronary syndrome (ACS) as the indication for PCI was compared in groups. In patients who underwent PCI for ACS, the incidence of short- (≤30 days) and long-term (>30 days after admission) clinical events (composite of myocardial infarction, cerebrovascular disease, coronary revascularisation, all-cause readmission, and mortality) and first non-fatal cardiovascular events were compared in groups.

Results: At the time of hospitalisation for PCI, 3,982 (73.7%) were on LLT (PRE-LLT), and 1,418 (26.2%) initiated LLT after admission (POST-LLT). Patients on PRE-LLT were significantly less likely to experience ACS before admission for PCI than were those commencing LLT after discharge (PRE-LLT 32.3% vs POST-LLT 56.9%; p<0.001), even after matching for baseline risk factors. Among these patients with ACS, patients on PRE-LLT were older than those on POST-LLT (mean 69.5±9.5 vs 65.0±10.0 years; p<0.001), and had a higher prevalence of cardiovascular risk factors including diabetes (31.5% vs 9.6%; p<0.001), hypertension (79.7% vs 51.7%; p<0.001), and renal failure (7.6% vs 2.0%; p<0.001). No difference was observed between groups in the risk of short- or long-term (median 2.0 years; interquartile range 1.0-3.0) post-PCI cardiovascular (hazard ratio [HR] 1.08; 0.83-1.40; p=0.55) or overall clinical events (HR 1.11; 0.93-1.32; p=0.26).

Conclusions: In patients with coronary artery disease, the risk of ACS is reduced by early initiation of LLT before revascularisation is required. Long-term outcomes of patients at high risk prescribed LLT before admission for ACS PCI may not differ from those of patients at lower risk commencing LLT after PCI for ACS.